MEDICARE: GORDON SACK MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1053642777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GORDON SACK MD PA

Provider Business Mailing Address
First Line	:	3339 FAIRVIEW ST
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-1903
Country	:	US
Telephone Number	:	713-910-6464
Fax Number	:	713-910-6995

Provider Business Practice Location Address
First Line	:	3339 FAIRVIEW ST
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-1903
Country	:	US
Telephone Number	:	713-910-6464
Fax Number	:	713-910-6995

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GORDON SACK
Credential	:	MD
Telephone Number	:	713-910-6464

Provider Enumeration Date	:	01/20/2010
Last Update Date	:	10/13/2010

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